Pre- and postoperative chemoendocrine treatment with or without postoperative radiotherapy for localy advanced breast cancer

Abstract

patients with localy advanced breast cancer (T3; T4n-h; any N; iV&) regardless of their hormonal receptor status, entered a trial to evaluate the contribution of radiotherapy when added to an intensive preoperative chemoendocrine regimen. Seventy-eight patients were ultimately disqualified. All patients underwent sequentially: (1) two cycles of chemotherapy: Day I-Oncovin 1.4 mg/m2, cyclophosphamide 350 mg/m2, Adriamycin 30 mg/m2; Day 2-methotrexate 20 mg/m2, 5-fluorouracil350 mg/m2 (in addition, antiestrogens were given to postmenopausal patients);(2) mastectomy with complete axillary dissection combined with oophorectomy in patients before and one year after menopause; (3) radiotherapy randomly to one-half of the patients; and (4) ten additional chemotherapy cycles as above, with antiestrogens to all patients. No serious local sequellae were encountered from mastectomy or radiotherapy, but complications of chemotherapy were numerous, particularly in irradiated patients. One death due to toxicity occurred after preoperative chemotherapy. The results to date suggest that in irradiated patients metastases may become enhanced and that their local disease is not more effectively controlled than in patients not having radiotherapy. Two factors may have been largely responsible for the differences observed between the two groups: the delay of chemotherapy in irradiated patients and the sustained immunosuppression known to occur after mediastinal radiotherapy.

Clinical practice guidelines for the care and treatment of breast cancer: 15. Treatment for women with stage III or locally advanced breast cancer

“…These trials are summarized in Table 2 (level I evidence) 11 and Table 3 (level II evidence). 61 There is a large body of level I and level II evidence demonstrating that locoregional radiotherapy following mastectomy in patients with node-positive disease treated with systemic therapy is associated with not only a reduction in locoregional recurrence but also an increase in overall survival (see guideline on postmastectomy radiotherapy). In the 3 largest trials of postmastectomy radiotherapy, 12%-14% of patients had stage IIIA disease.…”

“…Patients who are treated primarily with radiotherapy should be given tumouricidal doses to areas of bulk disease (60)(61)(62)(63)(64)(65)(66) …”

Management of patients with locally advanced breast cancer

“…It is clear that preoperative treatment and deferral of surgery do not increase rates of unresectability. On the contrary, approximately 80% of patients experience at least 50% shrinkage of the primary tumor mass, and only 2% to 3% have signs of progressive disease [15][16][17]. Fears that the surgeon will lose the so-called "window of opportunity" to resect chest wall disease are therefore unfounded, and preoperatively treated patients are likely to be rendered improved operative candidates.…”

“…Most patients therefore receive consolidation of their treatment with chest and regional radiotherapy as the final component of their multimodality therapy, and this sequence can reduce local failure rates by 50% [17]. However, decisions regarding the extent of locoregional irradiation are not necessarily straightforward when a dramatic response to neoadjuvant chemotherapy has been observed.…”

Radiation therapy for operable breast cancer

“…But other studies testing chemotherapy with or without radiation suggested that radiation could reduce survival after mastectomy, or interfere with the delivery of full doses of chemotherapy. [43][44][45] For selecting patients for radiation, the axillary lymph node status was well established as the most important predictor of locoregional recurrence. In many studies, this risk was >20% in subgroups of lymph-node-positive patients and increased with increasing numbers of lymph nodes and greater tumor size.…”